15110005M
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10726 LARRY WAY
CONTRACTOR: ANKUR AND POOJA PERMIT NO: 15110005
GUPTA
OWNER'S NAME: ANKUR AND POOJA GUPTA
10726 LARRY WAY DATE ISSUED: 11/02/2015
OWNER'S PHONE: 4088160623
CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic. #
To Clear Code Enforcement Case: REMODEL MASTER BATHROOM (60 SF);
REMODEL MASTER CLOSET (16 SF); INSTALL NEW LIGHTS AND
Contractor Date
OUTLETS IN MASTER BEDROOM.
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $9500
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 31602038.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: L1 Date:
granting of this permit. Additionally, the applicant understands and will comply
_
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Yd OWNER -BUILDER DECLARATION
u
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectio 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized ag nt: Date: i ^ 2-- 201S
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I!must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point sou ce regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
I
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT � BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingCakupertino.orgCUPERtINO 1511
000-S
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PROJECT ADDRESS t o -J 2Cs LA RF -Y IATA Y T C U PC47I AJ O
APN # /
OWNERNAME l�� KUP, Ci ftl �-PU-�
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E-MAIL ank-u"Y"Pa � tiat��.°�..3 e.
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STREET ADDRESS 10-42-4 L. ARR l I A
CITY, STATE, ZIP CU p R TIAID 9 5_ejP
FAX
CONTACT NAME N K , yF, U67 t9
P IONS /�/1f2 0 P//
E-MAIL
STREET ADDRESS f0'* ZCs L A K Z Y ok/A
CITY, STATE, ZIPa)p
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❑OWNER [-J OWNER -BUILDER.- ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 11 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAMEAv
LICENSE NUMBER R, g
BUS. LIC #
COMPANY NAME
E-MAILa
/,
FAX
STREET ADDRESS Q
ft"Cl
CITY, STATE, ZIP
C-3 1Z
PHONE
DESCRIPTION OF WORK
EXISTING USE I&
PROPOSED USE _ CONSTR.
TYPE
# STORIES
Bad rte,
�ci r
^�, ��
d�
U
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXIST'G `
AREA i
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10726 LARRY WAY
FEE
DATE: 11/02/2016
REVIEWED BY: PHUONG
APN: 316-02-038
BP#:
*VALUATION: 1$9,500
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Suppl. PC Fee: (j) Reg. 0 OTT
-0. 0 1
PENTAMATION 1 REAP1
PERMIT TYPE:
WORK
To Clear Code Enforcement Case: REMODEL MASTER BATHROOM 60 SF � REMODEL MASTER
SCOPE
CLOSET (16 SF); INSTALL NEW LIGHTS AND OUTLETS IN MASTER BEDROOM.
.A1ech. 111cm Check
=iiech. Permit Fee:
Other AJech. Insp.
Plumb. Plan Check
Plumb, Permit Fee:
Other.Plumb Insi�.
ilech. Insp. Fee: I Plumb. Inst. Fee;
NOTE. This estimate does not include fees due to other Departments (Le.
Elec. Plan Check 1 0.0 1 hrs $0.00
Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 1 0. 0 I hrs 1 $48.00
IElee. Imp. Fee:
Public Works, Fire, Sanitary Sewer District, School
Tivfrirf
'fn Thava faav ara haead n» tha nraliminary infnrmatinn availahle and are nnly an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E�' 7/U13,�
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
#
$48.00
Electrical
IBREMRECEP Recep/Switch/Outlets
Suppl. PC Fee: (j) Reg. 0 OTT
-0. 0 1
hrs
$0.00
PME Plan Check:
$0.00
= s.f
$645.00
Remodel, Bath (<=300 sf)
1REMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. OOT
0,0
hrs
$0.00
LL6_j s.f Remodel, Other
$431.00 1REMRESOT7H
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
Construction Tax,
Administrative Feer
1ADMIN
$45.00
O
0
Work Without Permit? Yes O No
$1,124.00
Advanced Planning Fee.
$0.00
Select a Non -Residential
Building or Structure
E
Travel Documentation Fee: 1TRAVD0C
$48.00
Strong �Motion Fee:
IBSEISMICR
$1.24
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
UBTc1TA =
$1,267.24
$1,124.00 TO TE
$2,39 1.24
Revised: 10/01/2015
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinoa()cuoertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS .�.Z6._ LAf-R APN_ BP#
OWNER NAMEAN-icuf- g,'PUQ- AWG SPT OWNER ADDRESS: �Z6 LA 2R Y klAg. .
DESCRIPTION OF WORK: A S T,5P— 49; /9 THkOUlv1
. -Meas te 9_&J eL'vs 6 T � Ess
We are providing you with an Owner' -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read -and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
BLF§@70,5j,"icensed
r" building permit that erroneously implies that the property owner is providing his or her own labor and material
penally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an o. person and his or her employees while working on my property. My homeowner's insurance may not
prow'�,,k�d,e coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insu`f�nce coverage for injuries to workers on my property.
,X4 I understand. building permits are not required to be signed by property owners unless they are responsible for
the q'%struction and are not hiring a licensed Contractor to assume this responsibility.
�K4 ?r3 I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
pr—ot c myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name Instead of my own.
A I understand Contractors are required by law to be licensed and bonded in California and to list their license
nu11 b rs on permits and contracts.
44 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tota alue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
con' idered an "employer" under state and federal law.
IlcG I understand if I am considered an "employer" under state and federal law, I must register with the state and
fedi al government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unegployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me t• serious financial risk.
,AWW. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
resid ntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
lice ed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is pe ormed under contract with a licensed general building Contractor.
Vltl,k. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any nancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
V
I understand I may obtain more information regarding my obligations as an "employer" from the Internal
ue Service, the United States Small Business Administration, the California Department of Benefit Payments,
e California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
e Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
party legally and financially responsible for proposed construction activity at the site address listed above.
. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
pplicable laws and requirements that govern Owner -Builders as well as employers.
Joa2. 1 agreeto notify the issuer of this form immediately of any additions, deletions, or changes to any of the
tion - have provided on this form. Licensed contractors are regulated by-laws designed to protectfhe..public. If
ntract with -someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a. result of a complaint—Your only remedy against unlicensed
Contractors maybe in -civil court. Itis also important for you -to understand that if an unlicensed Contractor or
employee of that individual or firm is injured .while working on your property, you maybe held liable for damages. If
you obtain a permit -as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or note
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name:
Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature. � ► -A
I Property Owner's Signature: 42_ Date: 11— Z-2015-
-
------------------------------------------------------------------------------------------------------------------------------------------
--
(NOTE: The following Authorization Form is required to be completed by the propertyov✓ner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
Owne?-Buildei-Form 2010.doc revised 04/14/10
CUPERTINO
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPUANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 o FAX (408) 777-3333 > building aacupertino.org
tStl600
jggffdM-� I0-426 LAP-teY WAY C(JPL--,e71No C41
PER��IT CANNOTFINAI,EI) ANDC®1ViI'lL1ETF�? ITN I II., THIS CERTIFICATE
HAS BE,ENaN_ . VrD LfM1EIi T07ME, BLL[ ,]D G-DIAr8I0.i�
PURPOSE
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMA'T'ION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM[
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above hasihave been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
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Smoke and. CO forni.doc revised 03118114
CUPERTINO
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501473255
(40$) 777-3228 • FAX (408) 777-3333 ^ buildinq(a7cupertino.orq
Owner Name %�� K Uir�. 9,moo T/ -i G Ui,-7-/a Permit No. � � 5 � / 0 d o `>
Address 110_42g� L/q(POZY WAY GU(?&�T/)140 CA 5 S`0/ 4-
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of fonn.
No Go to Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 -do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
�No Go to Question 3.
3. Is water service permanently disconnected for your building?
�❑,�Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Al ,/
NO Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Is `Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5. Ple�se check ONE of the following:
C Xy property is a single family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101:5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless, of whether property undergoes alterations or innprovernents).
I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page. .�,r U'L
Owner or Owner Agent's Signatur sJDatef: 1A — '3- Zol
Upon completing and si2nlnR this Certi
please return it to the Building Division in order to final Your buildine hermit.
SB407 2015.doc revised 08/26/15